How to heal health delivery [local health integration]

There are rising concerns about the LHINs, Ontario’s Local Health Integration Networks. On Aug. 10, Ombudsman André Marin accused at least some of the 14 LHINs of counting board members’ golf course and supermarket conversations toward their “community engagement” goals. In the past year several communities, including Niagara and Peterborough, have mobilized to fight planned LHIN reductions of hospital services.

Conservative Leader Tim Hudak has promised to dissolve the LHINs. NDP Leader Andrea Horwath more cautiously has called for a review and a moratorium on hospital restructuring.

At least some of the criticism of the LHINs is legitimate. However, all health systems in all jurisdictions have some regional approaches to planning. Not every town got a TB sanatorium in the 1920s or cobalt bombs for cancer in the 1940s. And the ministry strictly doles out cardiac or neurosurgery units now.

In 1974, Dr. Fraser Mustard’s Task Force recommended the creation of district health councils and local ministry operational units. Then-premier Bill Davis only established the district health councils as voluntary planning bodies. Thirteen years later, Dr. John Evans recommended a series of integrated regional models for Ontario to consider. Over the years, premiers David Peterson, Bob Rae, Mike Harris and Ernie Eves punted these ideas. Meanwhile, every other province created regional authorities. Finally in 2006, Premier Dalton McGuinty established the 14 LHINs.

Of course, government policies are mainly driven by politics, not necessarily good evidence. So why bother learning the evidence? Stephen Harper and Tony Clement’s cancellation of the long-form census has taken this attitude to new lows. And, partly because of this attitude, there is little rigorous evidence on the performance of the Ontario LHINs and other Canadian regional models.

However, it is safe to say that Ontario’s approach to LHINs is unwieldy. In other provinces, regional authorities directly deliver the vast majority of home-care services with their own staff. In Ontario, there are three levels of contracts before the patient gets a bath. The LHINs contract with community care access centres for home-care services. Then the CCACs send out RFPs (request for proposals) and eventually sign contracts with various for-profit and non-profit entities. Then the home-care agency signs contracts with individual workers, most of whom are non-unionized. The Ontario high foreheads cite this “purchaser provider split” as if it were a biblical prohibition. Other provinces cite this approach as proof of Ontario’s pride-goeth-before-the-fall exceptionalism.

The other provinces also at least had the political leadership to disestablish most of their hospital boards. The McGuinty government judged that Ontarians would resist a similar step here. However, as a result the LHINs are seen as just another administrative tier. And, partly because other corporate boards remained, the LHINs have very few expert human resources with which to fulfill their immense job descriptions.

Finally, the LHINs legislation doesn’t mention public health and there is little coordination between public health and the rest of the health system. The province’s H1N1 flu management problems last fall reflected this lack of integration.

Something will happen to the LHINs, probably after the next election. And, every other province has at least tinkered with their regional models.

Here’s some advice to the government as it reviews the LHINs and the governance of Ontario’s health-care system: Start with form following function. Some services, like cardiac care, cancer and emergency services need top-down command and control. Some services, like care of the frail elderly and health promotion, beg for freewheeling bottom-up, democratic, non-profit entrepreneurship.

In B.C., the provincial health services agency coordinates eight specialized agencies, including the B.C. Centre for Disease Control. Cancer Care Ontario plays a similar role for oncology services and could be a model for a provincial health agency in this province.

Ontario’s 80 community health centres are governed by elected community boards and typically engage hundreds of their residents every year. And that’s not counting chats in line at Tims!

Quebec’s 95 local health boards and England’s 151 Primary Care Trusts are much closer to their communities than Ontario’s 14 LHINs. Ontario should consider establishing democratic control at the local primary health-care level, where most health is delivered.

Finally, regional level governance could be established building on local primary health-care boards.

The LHINs have been a baby step to better integration. Ontario should review its regional model and then reorganize the governance of the health system to balance efficiency, effectiveness and community participation.

Dr. Michael Rachlis is a health policy analyst and an associate professor at the University of Toronto.